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Key issues faced by client

Discuss about the Case Study of Sandra.

The case study of Sandra, a 28 year old girl who was refereed to counseling by her GP had the following issues:

Conflict with partner: Sandra has been living together with Steven, however they have not married yet. Both of them have been dating since high school. However, the current problem in their relationship is coming up because of the disagreement between the two regarding the right time for marriage. This difference in views have led to heated arguments among them and scarred their warm relationship.

Lack of direction in life: Sandra is a solicitor and she recently got a new job in a large firm. Earlier she was working in a small law firm for five years. Despite this achievement, she is not content with her life. She lacks direction regarding her future goals in life and is unsure about her current job position.

Increase in mood swings: Mood swings is a major issue for Sandra as she is overwhelmed by hopelessness at times. Sometimes she feels very good and happy about herself but the feeling does not last long. She often feels worthless and has been experienced this feeling since adolescence. This negative feeling has become more intense now as she believes that she has not achieved what she had desired in life.

Issues in social interaction: Another challenge for Sandra is that she finds it difficult to interact with people. Often in social gathering, she has reported of being restless and irritated with people. This might hamper her relations in life. Although this has not affected her work life yet, however she feels this may affect her work in the future.

Negative feeling towards family members: Apart from her own personal goals, Sandra shows negative towards her family members too. She feels that as she is the eldest of the three children, her father has high expectation from her. This has overburdened her. In addition, she also feels that her mother does not provide her emotional support when she needs it the most

The analysis of Sandra’s issues shows that some information is still missing and knowing about that may help during the therapy session. The areas of life needing more information are:

Sandra’s goal in life: The case study mentions that Sandra is not good enough and not worthy. This is because she did not turned out to be a person she wanted to in life. However, there is no clarity regarding what was her aim in life. If the therapist can get the information regarding her past goals in life, it would help to identify the exact reason for Sandra’s disappointment. This would also help to interpret why Sandra has no directions in her life and is not sure about future aspirations.

Identification of areas of client life needing more information

Sandra’s behavior in social situation: The case analysis of Sandra shows she feels restless and irritable with people. However, the exact scenario or situation under which she has this feeling is missing. It might be possible that she prefers living alone or she gets irritated when someone bothers her unnecessarily. This information would help to interpret the factors that lead to feelings of irritation in Sandra.

Sandra’s father expectation towards her: Sandra reports that her father had higher expectations towards her than other siblings as she was the eldest. However, no detail is given regarding the exact expectation.. This information might help to determine the wish of her father that Sandra could not fulfill. This might also be the reason for Sandra’s feeling of worthlessness. This would help in addressing Sandra’s concern during counseling.

Previous counseling: It is not known whether Sandra has taken counseling before or not. This information might help to determine the reason for her visit and what was not addressed that she came for counseling again.

While working with Sandra, I would use the approach to cognitive behavior therapy and acceptance and commitment therapy for counseling her. The use of Cognitive Behavior Therapy (CBT) is appropriate for Sandra as it utilizes short term and goal oriented approach to problem solving. Cognitive behavior therapy is mostly given to individuals with range of issues such as relationship problems, anxiety, depression, drug abuse, and other issues in life. The goal of the therapy is to change pattern of thinking in affected person (Demner, 2016).  The technique is based on the assumption that a person’s mood is directly affected by their thought patterns. Therefore, it assist a person in recognizing their negative thought pattern, validate them and replace them with positive way of thinking. It assist client in understanding their problems and adapt new strategies to deal with issues. The combination of psychotherapy and behavioral therapy in CBT helps to modify thinking pattern and promote behavior activation in people to overcome obstacles that prevent them from living happily (Farmer & Chapman, 2016). Hence, I aim to use this technique to address negative feelings and disappointment in Sandra and change her thinking and behavior pattern. Another advantage of utilizing this technique in therapy session is that it takes very short time about one session per week lasting for 50 minutes.

Another approach that I aim to utilize during therapy session for Sandra is Acceptance and commitment therapy (ACT). This kind of therapy is provided to individuals with emotional and behavioral challenges in life. It is a strategy that teaches mindfulness skills to client by means of commitment and behavior changes strategies.  This approach enhances psychological flexibility in an individual so that they respond to situations based on what a particular situation demand and persist in new behavior and values as taught during therapy sessions (Hayes et al., 2013). ACT is based on the relational frame theory that serves to identify the war of clients with their own inner lives. A therapist then uses metaphor and experiential exercise to teach clients how to make health contact with their feelings, recontextualize event and commit to new and healthy behavioral changes in life (De Houwer, 2013). I aim to use the ACT strategy for Sandra because her thoughts patterns and attitudes is also a result of a war with her inner self and she needs to learn new ways to respond to life situations in a positive way. Hence, with this therapy, Sandra can learn ways to suppress and manage her negative emotions and introduce value based actions in her life.

Two chosen therapeutic approaches

Prioritizing client issue for CBT

As Sandra is suffering because of her negative and irrational thought patterns, I aim to use CBT approach to explore cognitive processes of Sandra and change her attitude and behavior towards life. The main issue that needs to be prioritized by this therapy is mood swings and feelings of disappointment in Sandra. This is important because it is affecting both her personal and social life.   During the therapy session, the focus will be on thoughts, images , belief and attitude of client. This would help to establish link between cognitive process of Sandra and how she behaves in life. This would help to identify the reasons for her being tearful and upset most of the time (Beck, Freeman, & Davis, 2015). I would also include her parents in some of the sessions to assess how she reacts in normal life events and gain more insight about her mood swings and upset feelings.

Another key issue faced by Sandra is that her feeling of worthlessness. CBT session aims to address this attitude of Sandra by asking her about the reasons for her dissatisfaction with current job. In addition, inquiring about her current goals and aspirations in life might also help to establish the link between her current achievements in life and her current feelings (Greenberg, 2017). Hence, the condition of hopelessness and restlessness can be addressed by this technique.

Prioritizing client issues of ACT

Through the use of ACT strategy, the client issue of mood swings and no directions in life will be addressed. As ACT approach establishes connection with the observing self, I will help Sandra to detach from negative thoughts and reduce worthless feelings in life. After the reduction of negative feelings, the client can eventually accept new behavioral change. Sandra will be asked to avoid exacerbating her feelings of worthlessness in life and instead strive for actions that enhance her confidence both in personal and professional life (Niles et al., 2014). Therefore, by means of ACT, I will promote psychological flexibility in Sandra.

Another issue that will be prioritized according to the ACT strategy is that of her attitude of self-doubt and pointless feelings in life. During the therapy session, I aim to engage in value clarification so to help define what values and aspirations care important in Sandra’s life. This would guide her to action based on her values. People who have painful emotions and negative feelings in life fail to choose value based action and the technique of mind liberation in ACT therapy helps people to act congruently with their feelings (Craske et al., 2014). Hence, with this approach it is expected that Sandra can lead a fulfilling life post therapy.

Rational for prioritizing client issue

Cognitive behavioral therapy

Technique used: CBT is based on psychodynamic theory, which explains that unconscious forces drive behavior of individual and technique of free association and transference helps to redirect feeling of clients and modify their thought pattern (Colarusso & Nemiroff, 2013). With this assumption, the first step that I would use during therapy session would be to openly interact with Sandra and let her express her feelings and thoughts in life. I will ask her what makes her upset. This will help to analyze any underachievement or personal issues in life that might be leading to sad feelings in her. I would also inquire about any past event or past relationship that has made her the person she is today. This is important to establish link between her feelings and behavior.

In the next step, I would employ the technique of Socratic questioning to challenge maladaptive thoughts of Sandra. For example I may ask her ‘ Due to think it is right to be dissatisfied even when you have got a lucrative job opportunity which many people yearn for and still cannot get?’. This technique would make the client question herself and apply logic to finally realize that the thought or feeling that she was having was not actually right (Kazantzis et al., 2014). This would help to Sandra to arrive at adaptive and realistic beliefs. Finally, after the validation of her irrational thought and feeling, I would help teach her practical ways to change her state of mind on a daily basis.

Evaluation: The CBT approach to counseling will work for client because it focuses on current problems in client instead of focusing on past events. The solution-based approach to modify cognitive process in an individual enables them to cope better with issues in life. Research also gives strong evidence regarding the effectiveness of CBT in addressing anxiety disorders, general stress, depression and anger problems in people (Hofmann et al. 2012). As Sandra is also suffering from stress due to mood swings and disappointment, this would help her too.

Technique used: While providing counseling to Sandra by the ACT technique, her past issues will be explored to see how she is not able to bring positive vibes in her life despite many positive occurrence. This would make the client accept the deficit within her in a positive way. I would help her in accepting her experience by compassionately stating that ‘ I understand you are having difficulty in letting go off the feeling of worthlessness, however we can work together to address this’. This action will motivate Sandra to commit to new action and establish new relationship with her life experience. I would guide her to choose values based action by inquiring what is more important for her at this point of life. This would help her to identify value-based action and make commitment change behavior and attitude to achieve those things which she values most in life (Niles et al., 2014).

Evaluation: ACT is distinct from other therapies as makes people accept unhealthy feelings and personal values within them and encourage them to learn healthier ways of living by committing to new behavior. Unlike cognitive therapy, it does not directly stop unwanted feelings in client, instead it encourages them to develop new and positive relationship with life experience (Öst, 2014).. Hence, this is going to be more effective for Sandra so that she learn new ways to make her life more fulfilling and adapt positive values to overcome feelings of worthlessness in life.


Beck, A. T., Freeman, A., & Davis, D. D. (Eds.). (2015). Cognitive therapy of personality disorders. Guilford Publications.

Colarusso, C. A., & Nemiroff, R. A. (2013). Adult development: A new dimension in psychodynamic theory and practice. Springer Science & Business Media.

Craske, M. G., Niles, A. N., Burklund, L. J., Wolitzky-Taylor, K. B., Vilardaga, J. C. P., Arch, J. J., ... & Lieberman, M. D. (2014). Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: outcomes and moderators. Journal of consulting and clinical psychology, 82(6), 1034.

De Houwer, J. (2013). Advances in relational frame theory: Research and application. S. Dymond, & B. Roche (Eds.). New Harbinger Publications.

Demner, A. R. (2016). Cognitive-Behavioral Therapy. Pocket Guide to Addiction Assessment and Treatment, 259.

Farmer, R. F., & Chapman, A. L. (2016). Behavioral activation. American Psychological Association.

Greenberg, L. S. (2017). Emotion-focused therapy of depression. Person-Centered & Experiential Psychotherapies, 1-12.

Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2013). Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior therapy, 44(2), 180-198.

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive therapy and research, 36(5), 427-440.

Kazantzis, N., Fairburn, C. G., Padesky, C. A., Reinecke, M., & Teesson, M. (2014). Unresolved issues regarding the research and practice of cognitive behavior therapy: The case of guided discovery using Socratic questioning. Behaviour Change, 31(01), 1-17.

Niles, A. N., Burklund, L. J., Arch, J. J., Lieberman, M. D., Saxbe, D., & Craske, M. G. (2014). Cognitive mediators of treatment for social anxiety disorder: comparing acceptance and commitment therapy and cognitive-behavioral therapy. Behavior therapy, 45(5), 664-677.

Öst, L. G. (2014). The efficacy of acceptance and commitment therapy: an updated systematic review and meta-analysis. Behaviour research and therapy, 61, 105-121.

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